In whose interest?

Thomas Nagel

It would be best not to have to die at all, but failing that, many of us would like to have some control over the time and manner of our deaths, should we find ourselves in a condition so hopeless that there is no point in going on. At this date, in most of the world, including Britain and most of North America, the legally permissible forms of such control do not include voluntary euthanasia or assisted suicide. A physician may not, in most jurisdictions, administer or prescribe for self-administration a lethal drug for the purpose of ending life, even at the explicit request of a fully competent patient. Yet a physician is legally permitted (sometimes legally required) to take other steps that hasten death, if requested to do so by the patient or a proxy: he may end or withhold treatment (chemotherapy, antibiotics, surgery); withdraw or fail to initiate life support (respirators, feeding tubes); give high doses of opiates to relieve pain or induce coma, where these may also shorten life.

In his lucid and powerful book, the Canadian philosopher L.W. Sumner argues that this distinction is indefensible. His target is what he calls the Conventional View, namely that there is ‘an ethical “bright line” between assisted death, on the one hand, and all other end-of-life measures which may hasten death, on the other’. By assisted death Sumner means either providing (assisted suicide) or administering (euthanasia) a lethal medication in order to cause the patient’s death as a means of relieving his suffering. Sumner argues that the differences between assisted death and the legally permitted measures, such as turning off a respirator, are for the most part morally irrelevant. He favours a regime like the one that now exists in the Benelux countries, where both assisted suicide and euthanasia are allowed, under carefully specified conditions.[*]

Sumner holds that end-of-life treatment, like all medical treatment, should be governed by two values: respect for the patient’s autonomy and concern for the patient’s well-being. Usually they coincide, but where autonomy is not possible, as with an infant, well-being must govern. And if autonomy and well-being conflict, in the decision of a competent patient, Sumner believes autonomy should take priority.

With respect to the value of well-being, the most important and obvious point to be made is that one is justified in hastening death only in cases where death is better or at least no worse for the patient than continued life. Death may either be good, when it ends intolerable suffering, or neither good nor bad, when it ends a state of irreversible unconsciousness. Normally, death is a great evil for the person who dies, which explains the stringency of prohibitions against killing; but death is not always an evil, by comparison with the alternative. Sumner accepts the ‘deprivation account’, according to which death is bad because it deprives us of the goods that would be brought by continued life. If continued life would bring nothing but misery, in the form of intractable pain, nausea, delirium and helplessness, then a death that relieves us of that misery is not bad but good. That is what leads competent patients in sufficiently dire conditions to refuse further treatment, request removal of respirators and feeding tubes, or ask for terminal sedation. Evidently, the same end could often be achieved more quickly and effectively by a lethal injection, so the value of the patient’s well-being does not draw a ‘bright line’ between assisted death and other measures.

The full text of this book review is only available to subscribers of the London Review of Books.

[*] Assisted suicide, but not euthanasia, is legal in Switzerland and in the states of Washington, Oregon and Montana in the US. The most unrestricted regime exists in Colombia, where the Constitutional Court struck down the prohibition of euthanasia in 1997, and no regulations have yet been put in place to govern the practice.

Letters

Thomas Nagel expresses some optimism about philosophy’s chances of altering public opinion on euthanasia and assisted suicide (LRB, 6 October). While it’s certainly useful to define the several points bearing on the distinction between killing and letting die, Nagel is curiously silent on the two issues most often appealed to by conservatives – slippery slopes and the sanctity of life. ‘Allow this,’ they say, ‘and we’ll soon be back in the death camps’; and: ‘Life is a gift from God, not ours to take away.’ The second claim is notoriously hard to budge and may well, in many cases, motivate the first.

Most of those who make some such appeal restrict it to human life, holding that all of us, in contrast to plants and other animals, have a special value just in virtue of being human. What’s hard to budge, then, is the religionist’s entrenched speciesism. Does this infect Nagel’s own position? Perhaps. He says, as if it’s obvious, that although I might choose to save five rather than one, I can’t kill the one to save five. But would he make this distinction if dealing with animal lives? Or would he, as seems more likely, join Nozick, with utilitarianism for animals, Kantianism for people: a rights-based approach for human beings, and aggregating and trade-offs permitted elsewhere?

This question bears on the trickier issue concerning those who are not, in the philosopher’s sense, fully persons. Only rarely does the Alzheimer’s sufferer wish to die, and only rarely, and coincidentally, is it in his interests to do so. And I’m inclined to agree with Nagel that it probably shouldn’t be up to me, via advance directives or a so-called living will, to determine his, or my, future fate. But is no one to have responsibility here? It may in the end be the state’s job to decide when enough is enough. And it may be that we’ll live to regret the passing of less transparency and technology-valuing times, when end of life issues were very often fudged, and pneumonia was welcomed as the old man’s friend.